The job description of a clinical documentation specialist requires a medical professional to work in an administrative capacity. Such specialists can work in hospitals, physician practices, clinics and other medical facilities.
A clinical documentation specialist has the task of managing the creation of clinical files and maintaining the files as part of a patient’s medical record.
Essential Duties and Responsibilities of a Clinical Documentation Specialist
•Collects information about patients’ diagnoses and enters it into computer databases.
•Assesses all patient medical documents to ensure accuracy.
•Tracks information on diseases.
•Educates medical coders and billers on standard procedures that must be followed when composing medical documents.
•Recommends strategies for improving record keeping processes.
•Ensures all clinical documents are in compliance with federal laws in terms of composition and secure storage.
•Analyzes medical information to assist healthcare staff in providing superior services for patients.
•Applies knowledge of medical terminology and medical procedures to properly evaluate clinical documents.
•Prepares written reports for public health officials who evaluate healthcare facilities.
•Interprets clinical reports to identify health-related patterns and assists in addressing patient health problems.
•Meets with clinical staff to explain reports.
•Ensures that records are kept in proper order so that patients’ health information can be easily located.
•Conducts research and performs administrative duties.
•Trains information specialists on proper methods of documentation and maintenance of medical records.
•Takes continuing education courses and stays up-to-date on changes in laws governing clinical documentation.
Required Knowledge, Skills and Abilities
•Must be highly detail oriented.
•Exceptional analytical and critical thinking skills.
•Excellent written and verbal communication skills.
•Must have superior organizational skills.
•Strong leadership skills.
•Must have excellent interpersonal skills.
•Must have good time management skills.
•Must have strong negotiation skills.
•Must have excellent computer skills and knowledge of software for database maintenance and electronic health record storage.
•Knowledge of clinical conditions and procedures, medical coding and basic documentation requirements.
•Knowledge of accepted quality assurance procedures.
•Knowledge of patient privacy laws.
Education and Experience
•Associate’s degree in Health Information Technology orApplied Sciences and a Licensed Practical Nurse or LPN designation.
•Bachelor’s degree in Health Information Technology and a Registered Nurse or RN designation.
•Master’s degree in Health Informatics or Health Information Management.
•Certified Clinical Documentation Specialist or CCDScredentials through the Association of Clinical Documentation Improvement Specialistsor ACDIS.
•Certification as a Registered Health Information Technician, or RHIT, from the American Health Information Management Association or AHIMA, or fromthe American Academy of Professional Coders, otherwise known as the AAPC.
•Must be able to work in a very fast-paced environment.
•Time will be spent looking at a computer screen and keyboarding.
•Must be able to view photographs of real surgical procedures.
•Must be able to effectively deal with physicians who are defensive about their documentation practices.
•Must be able to work normal business hours of 8:00a.m. to 5:00p.m. Monday through Friday and longer hours based on workload.
•Salaries range from $35,000 to $85,000 depending on the level of education, years of experience and location and size of the facility of employment.